[Right colectomy with regional anaesthesia and hypnosedation in ASA 3 patient]. / Colectomie droite sous anesthésie péridurale et hypnosédation chez une patiente ASA 3.

In high-risk anaesthetic patients, the choice of a preoperative anaesthesia remains a difficult challenge before performing a heavy surgery such as colon excision. Nowadays, hypnosedation may be considered as an additional anaesthetic technique given to be associated with local or regional anaesthesia, in order to permit more surgery possibilities in high risk patients.

[Administration of ketamine during induction and maintenance of anaesthesia in postoperative pain prevention]. / Apport de l'administration de kétamine à l'induction et en entretien anesthésique dans la prévention de la douleur postopératoire Essai clinique en oncologie.

INTRODUCTION: Carcinologic breast surgery is responsible of intermediary postoperative pain and needs 30% additional morphine. Now, morphine administration generates adverse effects. Publications about morphine saving effect of ketalar as antagonist of R-NMDA, administrated in perioperative increase are discussed. OBJECTIVE: To evaluate the morphine saving effect of ketalar in carcinologic breast surgery. PATIENTS AND METHOD: This phase III randomized and double-blind study includes 208 patients during 14 months. Surgery consisted in mastectomy with or without axillary lymph node dissection or lumpectomy with axillary lymph node dissection. Group K received ketalar at induction until the end of surgery. Group P (placebo) received physiologic serum in the same condition. During the postoperative first 48h, morphine's consumption and EN are measured. RESULTS: No significant difference between two groups was observed. The EN evaluation and morphine consumption remained the same in the two groups. Our results did not find any benefit with use of ketamine between axillary lymph node dissection and no axillary lymph node dissection group. CONCLUSION: Ketalar adjunction in our analgesic protocol did not induce significant morphine saving in carcinologic breast surgery.

Dimensions of cancer locus of control scale as predictors of psychological adjustment and survival in breast cancer patients.

The Cancer Locus of Control Scale, to investigate specific beliefs of control in cancer patients, was validated previously with an English-speaking population. This study tested the construct and concurrent validity of a 17-item French version of the scale and explored its relations with psychological adjustment and with adaptation assessed two years later. In a sample of 157 women diagnosed with a first breast cancer, the French version was administered along with the Body Image Questionnaire, the State-Trait Anxiety Inventory, the Perceived Stress Scale, the Social Support Questionnaire, and the Ways of Coping Checklist. A factor analysis performed on scores identified the three original factors: internal causal attribution, control over the course of the illness, and religious control. Internal causal attribution was associated with high scores for state and trait anxiety, negative body image, emotion-focused coping, and problem-focused coping. Control over the course of the cancer was positively associated with scores on both problem- and emotion-focused coping. Religious control was negatively associated with perceived stress. Emotional adjustment and quality of life were assessed in 59 of the 157 breast cancer patients two years after diagnosis and original testing. Hierarchical regression analyses indicated that internal causal attribution significantly predicted 38.1% of the variance in rated state anxiety. None of the dimensions of the Cancer Locus of Control Scale predicted the duration of survival measured two years later in 75 of the 157 patients.

[A new system for permanent venous access, Cathlink 20: prospective clinical study. 95 cases]. / Un nouveau système pour l'accès veineux permanent, le Cathlink 20: étude clinique prospective. A propos de 95 cas.

A prospective clinical study of Cathlink, a new venous access system, was conducted in 95 cancer patients requiring long-term venous access (three months or more). Safety and efficacy of the device were also evaluated. This single-center study was done at the Bergonié Center, Regional Cancer Control Center, Bordeaux, France, from February 1994 to June 1998. Emergency cases were excluded. All patients gave their informed consent. The protocol was approved by the Bordeaux Ethics Committee. Cathlink low and standard profile systems were implanted in the prethoracic region. The catheter was introduced into a vein of the superior vena cava system in all 95 patients. Mean number of patient days was 11,295, and mean number of days per patient was 205,3636. Of the 493 accesses, 421 (79%) were successful at the first try. As compared with conventional implantable catheter devices, flow and location were better but access was more difficult, a shortcoming that will probably be improved by use of the Cathlink 20 standard profile device. The system was perceived as providing "natural" venous access by the nurses, who are now more used to using short catheters than Huber needles. Another important consideration is the enhanced safety provided by this system (no needle recoil after removal, and therefore no risk of infection, in particular due to viral agents).

[Preventive analgesic effect of intraoperative administration of ibuprofen-arginine on postmastectomy pain syndrome]. / Effet analgésique préventif d'une administration périopératoire d'ibuprofène-arginine sur le syndrome douloureux postmastectomie.

The efficacy of preemptive analgesia on postoperative pain is discussed. From experimental neurophysiological data, the present policy of preventive analgesia aims at precluding modifications of the nervous system secondary to a nervous lesion and the appearance of chronic pain, particularly of the neurogenic kind. The post-mastectomy pain syndrome (PMPS) falls within the realm of neurogenic pain and is still poorly understood and underestimated. This study evaluated the preemptive effect of a perioperative administration of an oral non steroid anti-inflammatory, the ibuprofen-arginine, on PMPS. Thirty patients scheduled for partial or total mastectomy with axillary dissection were prospectively and randomly assigned to 2 groups. The ibuprofen-arginine group (group I) (n = 15), received an oral administration of 400 mg of ibuprofen-arginine, 90 min before surgery, 2 h after surgery and then every 8 h in the first 32 postoperative hours. The control group (group C) received in doubled blind a placebo at the same time. At 6 months, we looked after pain or dysesthesia. We confirmed the diagnosis of PMPS in presence of association of diagnosis criterias. Fourteen patients in each group have been included. Eighty-six percent of the patients (13 patients in group I and 11 patients in group C) presented at 6 months dysesthesia of the upper member ipsilateral to the mastectomy and/or the operated breast, appearing either immediately or after a laps of time. Nine patients (group I) and 6 patients (group C) had PMPS. Postoperative radiotherapy and lymphoedema were statistically associated with PMPS (p = 0.019 and p = 0.011). The perioperative preventive administration of a non-steroid anti-inflammatory drug reduces neither the incidence of pain in the first post-operative months, nor the appearance of PMPS at 6 months. These results suggest that others factors than the nervous lesion may play a role in the occurrence of PMPS, as radiotherapy, lymphoedema, but also psychosocials factors.

[Functional outcome of laparoscopically transposed ovaries in the multidisciplinary treatment of cervical cancers. Analysis of risk factors]. / Avenir fonctionnel des ovaires transposés par coelioscopie dans le traitement multidisciplinaire des cancers du col utérin. Analyse des facteurs de risque.

OBJECTIVES: To evaluate the place of ovarian transposition by laparoscopy in the treatment of cervical cancers. METHODS: From March 1992 to November 1994 at Institut Bergonié, 11 patients (mean age: 40 years; 36-44 years) with invasive squamous cell carcinoma of the uterine cervix stages Ib (4 cases) and IIb (7 cases) underwent lateral high ovarian transposition by laparoscopy performed during a staging inter-iliacal lymphadenectomy. There was no complication during surgery but one phlebitis occurred postoperatively. The treatment for the cervical cancer included: brachytherapy (11 cases), external beam radiotherapy (EBRT) (9 cases), surgery (6 cases), chemotherapy (2 cases). Ovarian radiation dosis was calculated and hormonal status assessed. RESULTS: Ovarian preservation was achieved in 30% of the cases. The mean lowest cumulative dosis to the ovaries was 1.78 Gy. Age was the most predictive factor for ovarian preservation. CONCLUSION: With ovarian laparoscopic transposition, ovarian function can be preserved in selected patients requiring first line radiotherapy for cancer of the cervix. After the age of 40 years, transposition should be restricted to small T1 tumors treated by brachytherapy. When EBRT is required for larger lesions, transposition should be reserved to younger patients.

[Patient-controlled analgesia in cancer pain: practical aspects]. / L'analgésie auto-contrôlée dans les douleurs du cancer: aspects pratiques.

Allowing a suffering patient with cancer to control his pain is a challenge that numerous medical teams intend to take up. Although the best treatment is the etiologic one, in many situations the symptomatic and adjuvant therapies are both indispensable. Among them, the patient controlled analgesia (PCA) is a concept referring to the management of the pain, but also to the administration of some analgesic drugs. Even with genuine advantages the limits of the PCA do exist and need to be well known. PCA is not limited to palliative treatment; it can be used in many circonstances during each evolutionary step of the cancer, temporarily or for longer periods, at the hospital and at home as well. All patients disposing of such an equiment could determine their own best level of analgesia, at the good time, depending upon the temporal variability of the pain and its previsibility or not. The availability and the pedagogic concern of the members of the team, the link between the patient and his family, the involvement of both the regular general practioner and the "algologic" team are essential to maintain the best effects of this method.

[Quality control of care in a surgical department. Experience of the Fondation Berganié]. / Contrôle de la qualité des soins dans un service de chirurgie. Expérience de la Fondation Bergonié.

Activity in a surgical department can be evaluated quantitatively, but is should also be assessed qualitatively. One way to control the quality of care is to determine as accurately as possible the incidence of pre- peri- and post-operative complications and to analyse these date in a critical comparative study. This was accomplished in the surgical department of the Fondation Bergonié, Bordeaux during three test periods over the last five years--March 1987 (127 patients), June-July 1989 (276 patients), and June 1991 (147 patients). Results of this analysis cannot validly be compared with those of other departments with different patient recruitment and activity functions. However, this study within a department with regular, homogeneous activity did demonstrate, over a period of several years, a clear reduction in operative mortality, essentially by improved control of infectious complications by the extensive use of prophylactic antibiotic therapy for all surgery with a septic risk or for debilitated patients. Results also demonstrated the low cost effectiveness of routine pre-operative exploratory examinations.

[Symptomatic treatment of pain in cervico-facial cancers]. / Traitement symptomatique des douleurs des cancers cervico-faciaux.

Pain is frequent in patients presenting cervico-facial cancers. It can be acute or persistent, or present at the morbid entity known as chronic pain. The specific anatomical site and the often poor environment explain that the physical disability related to pain is increased by multiple psychosocial problems. Multidisciplinary care management by several actors is required and can be facilitated by a simple decision-making model. The schema presented can be used to prompt discussion and criticism. It needs constant improvement and extensions in order to reach a consensual attitude towards this king of suffering but also towards other situations of pain care management frequently encountered in cancer patients as well as those with other pathologies.

Decrease in zinc serum concentrations after surgical intervention. A study of 87 cases.

The post-surgery zinc depletion reported by Hallböök in 1977 and subsequently confirmed by many authors is now well known. Our study concerns a homogeneous group of 87 female patients undergoing the same surgical procedure: simple or enlarged hysterectomy. Results confirm a mean 35% drop in serum zinc after surgery compared to initial values. The drop is mainly during the operation. A parallel zinc and albumin depletion was noted in 36 patients between the beginning and end of intervention. More systematic zinc supplementation could be proposed before surgery in patients presenting chronic zinc depletion.

[Adverse effects of interleukin 2]. / Effets secondaires de l'interleukine 2.

Interleukin 2, has frequent and important side effects. Toxic effects observed are systemic (fever, chills, malaise), hemodynamic (capillary leak syndrome, hypotension), cardiac (arrhythmia, infarction), renal (renal dysfunction), infectious (septicemia), cutaneous, hematologic, gastrointestinal, endocrinologic and metabolic. Side effects are dose-dependent, generally reversible, with a mortality from 1 to 3%. Regimens of administration and other cytokine combinations affect interleukin 2 toxicity. If the treatment of these side effects is well known, selection of patients and specialized care unit remain always necessary.

[Home parenteral nutrition in oncology, a information project]. / Nutrición parenteral domiciliaria en oncología, proyecto de informatización.

The increase in the indications for total parenteral nutrition (TPN) of long or medium term duration led to an investigation on a discontinued method during the night. The patient was thus free during the daytime. Cyclic parenteral nutrition (CPN) at home is a comfortable solution. Parenteral nutrition at home (PNH) enables the quality of life to be improved and also reduces the cost of the therapy, which may permit us to establish a structure for oncological patients to take advantage of PNH. In the specific case of oncology, we shall examine in the first place, the conditions, indications and counter indications, complications, advantages and structure operation. To improve on this method, we have introduced a data processing system that provides the doctor with more autonomy and assists in caring for the patient and in the therapeutical decision.

[Approach to therapeutic risk by study of operative mortality. From 102 postoperative deaths between 1975 and 1984 at the Fondation Bergonié]. / Approche du risque thérapeutique par l'étude de la mortalité opératoire. A partir de 102 décès post-opératoires survenus en 10 ans (1975-1984) à la Fondation Bergonié.

A retrospective analysis of operative mortality in the cancer surgery department of the Fondation Bergonié between 1975 and 1984 allowed priority objectives to be defined requiring maximum efforts of the treating team. During this decade, 18,582 patients underwent surgery; 15,794 "first hand" operations were for cases not previously treated. Amongst the latter, 102 died within 90 days of surgery, 45 due to multifocal or apparently isolated pulmonary infection and 57 without any known infectious context. Separating patients into two groups: periods 1975-1979 and 1980-1984, demonstrated a notable decrease in postoperative mortality from 68 to 34. This improvement was due mainly to a reduction in deaths from infection (from 37 to 8 patients in the period 1980-1984). This marked improvement was probably the result of various combined causes: Mastery of parenteral nutrition enabling patients to be operated upon in better condition, or to tolerate possible complications better; Use of routine antibiotic therapy before surgery to digestive tube or ORL regions. These encouraging result suggest the need for enlargement of indications for routine prophylactic antibiotic therapy.

Improved control of cisplatin-induced emesis with a combination of high doses of methylprednisolone and metoclopramide: a single-blind randomized trial.

Forty-seven patients undergoing their first course of chemotherapy containing cisplatin in combination with other drugs were randomized to compare the antiemetic efficacy of high dose metoclopramide vs. high dose methylprednisolone added to metoclopramide. The number of patients who experienced no emetic episodes was significantly higher with the combination regimen (P less than 0.01). In addition, both the mean number of emetic episodes (P = 0.01) and the duration of nauseas (P = 0.025) were decreased with the combination regimen. Both antiemetic regimens were well tolerated. Sex affected the response, with women having more nausea and vomiting than did men (P less than 0.05).

[Spontaneous regression of pulmonary images interpreted as metastases of kidney cancer. Apropos of 2 cases]. / Régression spontanée d'images pulmonaires interprétées comme métastases de cancer du rein. A propos de deux cas.

The authors report two cases of spontaneous regression of pulmonary metastases from hypernephroma; this is an exceptional event that occurs in 0.8% of metastasized renal carcinomas; spontaneous regression in all cancers as a group occurs in 0.0014% of cases. The theories postulated up till now to explain this phenomenon are unconvincing. The authors suggest the possibility of tumorous emboli: this event, that occurs mainly in those carcinomas with a propensity for extension to veins, such as renal carcinoma, choriocarcinoma, hepatoma and liver metastases, does not necessarily give rise to a metastasis. The evidence that leads to advocate nephrectomy in metastasized renal carcinoma are recalled and discussed.